Intercostal drainage tube insertion is an emergency as well as planned procedure. In emergency it is a one of the life saving procedures. That's why it is important to learn the anatomy and physiology behind insertion of ICD and what should be the ideal procedure and post procedure care.
Bag and Mask Ventilation By Sakun Rasaily @Ram K Dhamalaramdhamala11
Bag and mask Ventilation Presented by Sakun Rasaily,
(Pediatric Nurse, Pediatric ward , B.P. Koirala Institute of Health Science
Dharan, Sunsari (Nepal)
It is the fastest and most commonly practiced approach and allows visual inspection of the supraglottic areas for foreign bodies (e.g., false or loose teeth, aspirated objects) and other obstructions (e.g., tumors). The most important consideration in oral intubation is appropriate head position.
Intercostal drainage tube insertion is an emergency as well as planned procedure. In emergency it is a one of the life saving procedures. That's why it is important to learn the anatomy and physiology behind insertion of ICD and what should be the ideal procedure and post procedure care.
Bag and Mask Ventilation By Sakun Rasaily @Ram K Dhamalaramdhamala11
Bag and mask Ventilation Presented by Sakun Rasaily,
(Pediatric Nurse, Pediatric ward , B.P. Koirala Institute of Health Science
Dharan, Sunsari (Nepal)
It is the fastest and most commonly practiced approach and allows visual inspection of the supraglottic areas for foreign bodies (e.g., false or loose teeth, aspirated objects) and other obstructions (e.g., tumors). The most important consideration in oral intubation is appropriate head position.
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
Access to abdominal cavity in Laparoscopy is often associated with various injuries. Debate about Open Vs Verss needle access is still not settled. This presentation highlights the literature review, possible problems associated with abdominal wall access through Veress needle and their management.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. Insufflator
I. Check the insufflator to assure that it is functioning properly
II. Connect the sterile insufflation tubing (with in-line filter) to the
insufflator.
III. Turn the insufflator to high flow (>6 L/min); with the insufflator
tubing not yet connected to a Veress needle, the intra-
abdominal pressure indicator should register
IV. Lower the insufflator flow rate to 1 L/min. Kink the tubing to
shut off the flow of gas. The pressure indicator should rapidly
rise to 30 mmHg and flow indicator should go to zero
4. • Next, test the flow regulator at low and high inflow. With the
insufflator tubing connected to the insufflator and the Veress
needle (before abdominal insertion), low flow should register 1
L/min and at high flow should register 2–2.5 L/min; measured
pressure at both settings should be less than 3 mmHg. A
pressure reading 3 mmHg or higher indicates a blockage in the
insufflator tubing or the hub or shaft of the Veress needle
• Maximal flow through a Veress needle is only about 2.5 L/min,
regardless of the insufflator setting because it is only 14 gauge.
• A Hasson cannula has a much larger internal diameter and can
immediately accommodate the maximum flow rate of most
insufflators (i.e., >6 L/min)
5. • During most laparoscopic procedures, the
pressure limit should be set at 12–15 mmHg;
intra-abdominal pressures higher than this
limit can diminish visceral perfusion and
venacaval return, but may be required in
obese individuals to achieve adequate
visualization.
6. Veress Needle
• The former is a one-piece plastic design (external diameter, 2 mm; 14
gauge; length, 70 or 120 mm), whereas the latter is made of metal and can
be disassembled.
• Check the Veress needle for patency
7. Closed” Technique with Veress Needle
I. Umbilical Puncture :
Place the supine patient in a 10–20° head-down position
If there are no scars on the abdomen, choose a site of entry at
the superior or inferior border of the umbilical ring.
Immobilize the umbilicus and provide resistance to the needle.
Next, make a stab incision in the midline of the superior or inferior
margin of the umbilicus. With the dominant hand, grasp the shaft
(not the hub) of the Veress needle like a dart and gently pass the
needle into the incision—either at a 45° caudal angle to the
abdominal wall (in the asthenic or minimally obese patient) or
perpendicular to the abdominal wall in the markedly obese patient.
8. • There will be a sensation of initial resistance, followed by a give, at
two points. The fi rst point occurs as the needle meets and traverses
the fascia and the second as it touches and traverses the
peritoneum.
• Connect a 10-mL syringe containing 5 mL of saline to the Veress
needle. There are fi ve tests that should be performed in sequence to
confi rm proper placement of the needle.
9. I. Aspirate to assess whether any blood, bowel contents, or
urine enter the barrel of the syringe.
II. Instill 5 mL of saline, which should flow into the
abdominal cavity without resistance.
III. Aspirate again. If the peritoneal cavity has truly been
reached, no saline should return.
IV. Close the stopcock and disconnect the syringe from the
Veress needle, then open the stopcock and observe as
any fl uid left in the hub of the syringe falls rapidly into
the abdominal cavity (especially if the abdominal wall is
elevated slightly manually). This is the so-called drop
test. If free fl ow is not present, the needle either is not in
the abdominal cavity, or it is adjacent to a structure
10. • Finally, if the needle truly lies in the peritoneal cavity, it
should be possible to advance it 1–2 cm deeper into the
peritoneal cavity without encountering any resistance.
Specifi cally, the tip indicator or the hub of the needle
should show no sign that the blunt tip of the needle is
retracting, thereby indicating the absence of fascial or
peritoneal resistance. Similarly, resistance to the needle tip
may be caused by impingement on intraabdominal viscera
or adhesions.
• Always be cognizant of anatomic landmarks when placing
the needle, and carefully stabilize the needle during insuffl
ation. Minimize sideto-side and back-and-forth movements
of the needle to avoid inadvertent injuries.
11. • After ascertaining that the tip of the Veress needle lies freely in
the peritoneal cavity, connect the insuffl ation line to the Veress
needle. Turn the fl ow of CO 2 to 1 L/min, and reset the indicator
on the machine for total CO 2 infused to 0. The pressure in the
abdomen during initial insuffl ation should always register less
than 10 mmHg.
• If high pressures are noted or if there is no fl ow because the 15
mmHg limit has been reached, gently rotate the needle to
assess whether the opening in the shaft of the needle is resting
against the abdominal wall, the omentum, or the bowel. The
opening is on the same side of the needle as the stopcock. If
the abdominal pressure remains high (i.e., needle in adhesion,
omentum, or preperitoneal space), withdraw the needle and
make another pass of the Veress needle
12. • repeat this process several times until you are certain that
the needle resides within the peritoneal cavity. Do not
continue insufflation if you are uncertain about the
appropriate intraperitoneal location of the tip of the Veress
needle. Multiple passes with the Veress needle are not
problematic, provided the error is not compounded by
insufflatin7g the “wrong” space.
• One of the first signs that the Veress needle lies freely in
the abdomen is loss of the dullness to percussion over the
liver during early insufflation.
• if CO 2 bubbles out along the needle’s shaft during
insufflation, suspect a preperitoneal location of the needle
tip.
13. • Monitor the patient’s pulse and blood pressure closely for a
vagal reaction during the early phase of insufflation. If the
pulse falls precipitously, allow the CO 2 to escape,
administer atropine, and reinstitute insufflation slowly after
a normal heart rate has returned.
• After 1 L of CO 2 has been insufflated uneventfully,
increase the fl ow rate on the insufflator to 3-6 L/min When
the 15 mmHg limit is reached, the flow of CO 2 will be cut
off. At this point, approximately 3–6 L of CO 2 should have
been instilled into the abdomen When percussed, the
abdomen should sound as though you are thumping a ripe
watermelon.
14.
15. • Drop test (Epidural space test):
- a drop of water --- suctioned into
peritoneal cavity
• Syringe barrel flow test:
• Manometer test (free flow of gas):
- elevation of abdominal wall, falling
insufflation pressure ( < 5-6 mmHg at
1.0L/min flow )
• Loss of liver dullness early in insufflation
16. • Aspiration-instillation-aspiration test (Syringe aspiration test):
- Aspiration : blood, bile, bowel content, urine
- Instillation : 10cc N/S--- if any resistant
- Re-aspiration : no fluid aspirated
• Waggling test (Lateral needle swing test): (potentially
dangerous)
- base on tactile confirmation of a free-
moving tip
- pivot point at the tip --- adhesion or pre-
peritoneal
- pivot point at the fascia --- intraperitoneal
17. Alternate Puncture Sites
• Prior abdominal surgery mandates care in selection of the
initial trocar site, and may prompt consideration of use of
the open technique.
• If the previous incisions are well away from the umbilicus,
the umbilical site may still be used, with either a closed or
open technique.
• lateral to the rectus muscles.
• In general, patients with prior low vertical midline scars
should be approached through a trocar placed at the lateral
border of the rectus muscle in either the left or right upper
quadrant.
18. • With previous upper vertical midline incision or multiple incisions
near the midline, the right lower quadrant site may be appropriate.
Alternatively, it is possible to perform an open technique with the
Hasson cannula.
• Upper abdomen. In the upper abdomen, the subcostal regions are
good choices. Carefully percuss the positions of the liver and spleen
to avoid inadvertent injury to these organs, and decompress the
stomach with a nasogastric or orogastric tube.
• Lower abdomen. The right lower quadrant, near McBurney’s
point, is preferable to the left because many individuals have
congenital adhesions between the sigmoid colon and anterior
abdominal wall. Decompress the bladder when using a closed
insertion technique at, or caudad to, the umbilicus.
19. Placement of Trocar
• Always inspect the trocar to ensure that all valves move
smoothly, that the insuffl ation valve is closed (to avoid
losing pneumoperitoneum), and that any safety shields
work properly. Make sure that you are familiar with the
trocar; with the variety of designs available, it is not
uncommon to be handed a different device.
• Once you have attained a full pneumoperitoneum, remove
the Veress needle.
• In a slender individual, the distance to the viscera and
retroperitoneal structures is slight, and it is prudent to aim
the trocar down into the pelvis. In an obese patient, this is
less a problem and the trocar may be passed in a more
direct path.
20. • Patient in a horizontal position
• Skin incision should be large enough to prevent any resistance
• A stretched middle finger can prevent over-insertion (palming
technique)
• Z-technique (prevention of incision hernia)
23. Open” Technique with Hasson Cannula
• The open (e.g., Hasson 1971 ) cannula provides the
surgeon with an alternative, extremely safe method to enter
the abdomen, especially in a patient who has previously
undergone intra-abdominal procedures.
• The open cannula consists of three pieces: a cone-shaped
sleeve, a metal or plastic sheath with a trumpet or flap
valve, and a blunt-tipped obturator .
• Make a 2–3-cm transverse incision at the selected entry
site (in the quadrant of the abdomen farthest away from
any of the preexisting abdominal scars or in the
periumbilical skin crease if there has been no prior midline
surgery).
25. • Dissect the subcutaneous tissue with scissors, and identify and incise
the underlying fascia Exposure is usually facilitated by the use of small
L - or S -shaped retractors. Gently sweep the preperitoneal fat off the
peritoneum in a very limited area. Grasp the peritoneum between
hemostats and open sharply. This incision should be just long enough
to admit the surgeon’s index finger .
26.
27. Avoiding, Recognizing, and Managing
Complications
1. Bleeding from abdominal wall :
a. Cause and prevention: This problem usually manifests itself as a
continuous stream of blood dripping from one of the trocars, and/or as blood
seen on the surface of the abdominal viscera or omentum. Less commonly,
delayed presentation as a hematoma of the abdominal wall or rectus sheath
may occur.
This source of bleeding is usually the inferior epigastric artery or one
of its branches
a. Recognition and management : To determine the point at
which the vessel is injured, cantilever the trocar into each of four
quadrants until the flow of blood is noted to stop.
28.
29. Visceral injury
I. Cause and prevention : Careful observation of the steps just
enumerated will minimize the chance of visceral injury. However,
placement of the Veress needle is a blind maneuver, and even with
extreme care puncture of a hollow viscus is still possible.
II. Recognition and management : If aspiration of the Veress
needle returns yellowish or cloudy fl uid, the needle is likely in the
lumen of the bowel. Due to the small caliber of the needle itself,
this is usually a harmless situation. Simply remove the needle and
repuncture the abdominal wall.
After successful insertion of the laparoscope, examine the abdominal
viscera closely for signifi cant injury.
30. Major vascular injury
I. Cause and prevention :Major vascular injury can occur when
the sharp tip of the Veress needle or the trocar nicks or lacerates a
mesenteric or retroperitoneal vessel. It is rare when the open
(Hasson cannula) technique is used .
II. Recognition and management : If there is a central or
expanding retroperitoneal hematoma, laparotomy with
retroperitoneal exploration is mandatory to assess for and repair
major vascular injury.
31. • On removal of a laparoscope. Check by direct visualisation
that there has not been a through-and-through injury of
bowel adherent under the umbilicus
• Secondary ports must be removed under direct vision to
ensure that any haemorrhage can be observed and treated,
if present.
32. Generation of Working Space:
Extraperitoneal Approaches
was first described by Bartel in 1969. Wickham and Miller
described the use of carbon dioxide (CO 2 ) and videoscopic
control in 1993 while performing a ureterolithotomy. The initial
difficulties using this approach mainly related to inability to create
a sufficient pneumoretroperitoneum. Gaur introduced balloons for
retroperitoneal dissection in 1993, and Hirsch and coworkers
described the use of a trocar mounted balloon for extraperitoneal
dissection in 1994.
33. • Today, the EES is most commonly utilized for totally
extraperitoneal (TEP) inguinal herniorrhaphy .
• There are both advantages and disadvantages to this approach .
34.
35. Anatomic Considerations
I. Preperitoneal space—between the transversalis fascia and parietal
peritoneum of anterior abdominal wall. The inferolateral border
includes the space of Bogros which is lateral to the epigastric
vessels and dissected in the TEP inguinal herniorrhaphy.
II. Retroperitoneal space—containing the aorta, vena cava, and the
retroperitoneal organs.
III. Subperitoneal space—surrounds the pelvic organs anteriorly
beginning at the space of Retzius between the pubic bone and the
bladder and posteriorly with the pararectal spaces.
IV. The lumbar retroperitoneal space is the posterior continuation of
the space of Bogros bounded by the vena cava and aorta medially,
the psoas dorsally, the colon ventrally, and transversalis fascia
laterally. This space contains the kidney, adrenal, ureter, and
Gerota’s fascia .
36.
37.
38. Access to the Extraperitoneal Space
• Depending on the type of procedure, the patient is either
placed in supine or lateral decubitus position. There are
three basic ways to gain access to the extraperitoneal
space.
• For TEP approach, the incision is typically periumbilical, on
the opposite side of the hernia. For access to
retroperitoneal organs, the incision is usually 2 cm above
iliac crest in posterior axillary line.
39. The open approach
Make a 2-cm incision overlying the space to be developed.
Bluntly dissect down to the preperitoneal space and
develop this space.
Place a Hasson cannula or a structural balloon trocar
Continue dissection with laparoscope or balloon dissector
40. Use of a lens-tipped trocar
Make a 12-mm skin incision over the desired location.
Place a 0° laparoscope into a lens-tipped trocar.
Use this to penetrate the layers of the abdominal wall
under direct vision.
Once the correct plane is achieved, place a Hasson
cannula or structural balloon trocar and continue
dissection
41. The closed approach using the Veress needle
• Insert a Veress needle suprapubically through the fascial layers into
the preperitoneal position. The needle will traverse two palpable
points of resistance (the anterior rectus sheath and transversalis
fascia).
• Insuffl ate 1 L of CO 2 .
• Make a skin incision lateral to the midline.
• Insert a 10-mm trocar, directed caudad, until the gas-fi lled space is
entered.
• Place the laparoscope into the trocar and use it to dissect the space
while insufflating CO 2 .
• The major disadvantage is that this procedure is relatively “blind” and
risks visceral and vascular injury as well as penetration of the
peritoneum. If this technique is used to develop the lumbar
retroperitoneal space, fl uoroscopic control with ureteral and nephric
imaging is essential.
42. Dissection of Extraperitoneal Space
• Operating laparoscopes have a 5-mm instrument channel (in a 10-mm
laparoscope). These allow dissection under direct vision during
insufflation of CO 2 .
• Alternatively, a 30° laparoscope can be used alone to open the space
by sweeping tissue away while insufflating CO 2 .
• Balloon dissection is the most popular, if most expensive, method of
developing the extraperitoneal space. It may be beneficial,
particularly early in the surgeon’s experience with this procedure.
43. Maintenance of Extraperitoneal Space
• Insufflation to 8–10 mmHg CO 2 will maintain a working space while
avoiding excessive subcutaneous emphysema.
• Planar abdominal wall-lifting devices, allow gasless extraperitoneal
endoscopy using conventional instruments.
• In TEP hernia repairs, the structural balloon trocar replaces a Hasson
cannula and displaces peritoneum posteriorly while providing a seal
between skin and fascia and providing access for the laparoscope.
• Peritoneal retraction devices are necessary to displace the peritoneal
sac for lumbar and iliac extraperitoneal laparoscopy. These
instruments can be used in a gasless or gas extraperitoneal
laparoscopic procedure.
44. Potential Problems
• Penetration into the peritoneal cavity
• Peritoneal holes
• Venous bleeding
Prior retroperitoneal dissection obliterates the potential
space and is a contraindication to the extraperitoneal
approach.
• This procedure is more difficult in obese patients , as
excess adipose tissue in the extraperitoneal space will
obscure planes and landmarks.